Provider Demographics
NPI:1750571956
Name:ABOU-MEDIENE, SHARIFA M (MD)
Entity type:Individual
Prefix:DR
First Name:SHARIFA
Middle Name:M
Last Name:ABOU-MEDIENE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7489 TROUTWOOD DR
Mailing Address - Street 2:APT 3A
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7503
Mailing Address - Country:US
Mailing Address - Phone:313-467-3630
Mailing Address - Fax:
Practice Address - Street 1:303 FRASER DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3712
Practice Address - Country:US
Practice Address - Phone:912-877-2227
Practice Address - Fax:912-877-2332
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089798208000000X
GA78683208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG00233EOtherMEDICARE
GA003199810EMedicaid